More than 300 medication errors took place at Pennsylvania hospitals across the state during the past decade due to incorrect settings in hospital electronic health record (EHR) systems, a Pennsylvania Patient Safety Authority report reveals.

The errors were related to default settings used in EHR systems. Default settings are commonly used to populate information for things such as commonly prescribed dosing protocols, and time for therapy delivery or lab draws.

The intent of the default values is to improve efficiency and standardization, but the defaults can cause harm when not used properly.

Analysts identified a total of 324 adverse events related to EHR software defaults. The three most common errors included wrong time errors, wrong-dose errors and inappropriate use of an automated stopping function (meaning the medication was stopped prematurely). In some cases, the default route of medication administration (oral, IV, etc.) did not match the intended route of administration.

The three most common causes for errors were a failure to change the computer system’s default value, user-entered information being overridden by the computer system, and failure to completely enter information, which resulted in the computer inserting information in the blank parameters.

The majority of the errors (314) were reported as “event, no harm,” meaning that there was no adverse outcome for the patient. Six events were reported as “unsafe conditions” that did not lead to patient harm.

Two errors involved temporary harm to patients that required treatment or intervention. In one case a patient was given a higher than intended dose of muscle relaxant. In the second case a patient was given an extra dose of morphine.

Two cases involved temporary harm to patients requiring a prolonged hospitalization. The first of these involved a patient developing a fever after an antibiotic was incorrectly discontinued. In the other case, a patient never received an ordered antidiuretic.

Paying attention to how time information is entered into the system and developing EHR maintenance policies to make sure EHR defaults match current clinical practice guidelines may help prevent errors like these in the future, the researchers suggested.

References

  1. Sparnon E. Pa Patient Saf Advis. 2013;10(3):92-95.